Division of Behavioral Health Services Documents/Coordinating... · Division of Behavioral Health Services Prevention Services ... The RPPs are working with Je ssica Hestand to receive

Division of Behavioral Health Services

Prevention Services

Progress Report

for

Regional Prevention Providers

APPLICATION DEADLINE: January 12, 2015

DIVISIONOFBEHAVIORAL HEALTH

SERVICES (DBHS)

COVER PAGE

PREVENTION SERVICES REGIONAL PREVENTION PROVIDERS

Name of Organization: University of Arkansas for Medical Sciences

**AASIS Vendor Number: 9901500015

Address: 4301 West Markham, Slot 812

Little Rock, AR 72205

Application Submitted by (Name):Suzanne Leslie

Title:Director of Contract Services

Phone: 501-686-6134 Fax: 501-686-8628

Email:[email protected]

DBHS Service Region #: 7

DBHS Counties Served: Calhoun, Columbia, Dallas, Nevada, Ouachita Hempstead,

Howard, Lafayette, Little River, Miller, Sevier, and Union

Requested Amount:170,406

Please Submit One (1) Original and Two (2) Copies to:

ARKANSAS DEPARTMENT OF HUMAN SERVICES

DIVISION OF BEHAVIORAL HEALTH SERVICES 305 S. PALM STREET

LITTLE ROCK, ARKANSAS 72205 * Before submission please verify your vendor number. If your organization has an AASIS vendor number on file with the State, please write the name exactly as it is in the vendor system. If you do not have a number on file, if awarded, DBHS will contact you and provide information about obtaining the required vendor number. Completion Instructions

Regional Prevention Provider Progress Report

NOTE: Please complete information about progress made toward each deliverable and plans for completing each deliverable for the remainder of State Fiscal Year 15 and for State Fiscal Year 16. Space is provided at each deliverable and space will expand as information is entered. Reference the full deliverable and indicators later in this document.

A. Program Deliverables:

The contractor will raise community awareness of behavioral health prevention through media campaigns and public presentations and dissemination of prevention materials such as pamphlets and brochures, etc.by promoting and attending awareness events. Progress:UAMS South Prevention has participated in various community awareness events since July including those planned by other community agencies and those facilitated by ours. We have provided brochures and promotional items for county fairs, back to school events, faith based events, coalition meeting, youth programs, and many other organizations. In August, Pam attended a back to school bash where over 500 youth and adults attended she also attended a teacher health fair where materials were distributed to around 300 faculty and staff these events were held in El Dorado (Union County). Pam attended a health fair and back to school bash in Mineral Springs were over 200 youth and adults attended. The UAMS south Prevention RPP provided a table of materials and promotional items at each event. Pam presented information to the youth at Foreman Schools about e-cigs, smoking, and chewing tobacco. Tia attended a family health fair in Hope (Hempstead County) were over 500 youth and adults attended. A table with prevention materials and promotional items were available. In September, UAMS South Prevention presented information to the Miller County safety baby showers about e-cigs and the dangers for pregnant women. Pam participated in a Suicide Prevention walk in Miller County. She also visited with the Nashville school district and Cossatot Community College in Ashdown to discuss driving safety issues. In October, literature was given in Texarkana for a safety baby shower. UAMS South attended several Red Ribbon week eventsin Union, Columbia, and Miller counties were brochures, red ribbon and promotional items were available. Kim attended the MRMC Kids’ health fair providing books and crayons to children and other prevention materials to parents. Kim also attended the Albemarle Health Fair with a prevention table providing materials for approximately 300 employees. On, October 29, Kim attended a Fall Fun Festival at South view Church of Christ. Kim gave out red ribbons, brochures, and promotional items and meets other vendors who were added to her contact list. On October 31, Kim planned “Boo to Drugs” event in which UAMS South staff dressed up in costumes and wore red ribbons. UAMS South Prevention was not able to attend the Youth Stomp Out event held on October 9, at the Grandview Education Center in Hempstead County, however Tia and Pam provided materials and promotional items for the event. In November, Tia provided the Munn’s Chapel women department with materials and promotional items for the Women Conference which was held on November 15 there were approximately 200 people who attended the conference. Pam hosted and Kim attended theGreat American Smoke out Luncheon in Texarkanaat UAMS Southwest were materials and a presentation was given. Kim attended a Mass flu clinic in Union and Calhoun County were a prevention booth was set-up with materials and promotional items. Plan: Our plan is for each staff member to continue attending any coalition meeting, health fairs, or awareness meetings that are held in our counties in the future. Through the coalitions, health fairs, and board meeting, we meet new contacts who require our services and are part of many public awareness efforts for prevention and health matters. We will continue to publish our newsletters and participate in media events providing PSAs and articles throughout the year.

B. Program Deliverables:

The contractor will utilize the Strategic Prevention Framework (SFP) in planning behavioral health prevention projects: Special projects specifically for Military Yellow Ribbon (August), Fetal Alcohol Spectrum Disorder (September), Suicide Prevention (September), Recovery Month (September), Red Ribbon Week (October), Domestic Violence Month (October), Great American Smoke-out (November), Drugged and Drunk Driving (December), Gambling (March), Kick Butts Day (March), Child Abuse Awareness Month (April), National Prevention Week (April), Alcohol Awareness (April), National Prevention Week (May), Mental Health (May), and No Tobacco Day (May). Progress:The SPF was utilized in planning community awareness projects in our region by working with youth groups in Nevada about underage drinking and prescription drugs. Kim worked with PRIDE, TOUCH Coalition, DASH Coalition, UCRC Coalition to assess the challenges of Smokers and risk/protective factors Youth facing the dangerous of smoking. She utilized the data from the 2013-2014 APNA survey, Kim along with the aforementioned groups assess the needs of the target group, realize capacity, made a plan, implemented projects, and then evaluated the projects through oral surveys and sign-in sheets. Pam, Tia and Kim all distributed email blast pertaining to bullying, international survivors of suicide day, red ribbon week, national recovery month, veterans and patriots appreciation day, and The Great American smoke out. Kim visited all local school in Columbia count to share literature on the problem of Drugged and Drunk Driving based on the APNA data for this county- 3-D is an area of concern. Plan:Our plan is to continue providing public awareness of special behavioral health initiatives each month. We will take part in the ones that are best received by our counties. We will continue to participate in any events, provided publicity about them, and encourage support throughout our region. UAMS South RPPs are working together on upcoming events and presentation within our region.

C. Program Deliverables:

The contractor will operate as “Prevention Outlet” for dissemination of information and behavioral health prevention materials (pamphlets and brochures, videos, etc.). Progress:UAMS South has prevention outlets set up in the Magnolia office and the Texarkana office. The Magnolia office has a display of materials set-up in two difference locations in the education center. The Magnolia office also has a storage room with boxes of materials and promotional items. The Texarkana office has library set-up with displayed materials for the public to utilize. Other agencies and groups in the area also display out material including PRIDE youth programs, the boys and girls clubs, area churches, schools, medical facilities, treatment facilitates, health units, law enforcement agencies, and other public venues.

Plan:We will continue to provide materials in small outlets in our regions as we become aware of the needs. We would like to provide more outlets throughout our region in places such as colleges, faith based organizations, and libraries. Our material is delivered throughout our counties from co-workers and other partners. We received new literature from DBHS and we are looking forward to providing the new material to our communities.

D. Program Deliverables:

The contractor will become knowledgeable in various prevention methodologies by attending the Division of Behavioral Health Services (DBHS) identified Training of Trainers (TOT) and other identified TOT. The contractor will be required to conduct each of the trainings in the region. Progress: Pam, Tia, and Kim attend a number of online Strategic Prevention Framework (SPF) and Technical Assistance(TA) training during the month of September and October. Kim and Pam attended the DBHS Substance Abuse Prevention Skills Training (SAPST) in Little Rock, AR held September 30-October 3. Pam, Tia, and Kim participated in Mandatory DBHS Quarterly meeting in Little Rock, AR. Tia, Pam, and Kim participated in Certification Meeting with Jessica Hestand, Arkansas Prevention Certification Board Administrator.

Plan: All RPPs will continue to attend any DBHS identified trainings of trainers and will replicate them in our area as directed.

E. Program Deliverables:

The contractor will attend additional trainings annually and become diverse in behavioral health prevention (treatment, mental health, and recovery) programming for primary, secondary, and tertiary prevention for selected, indicated, and universal populations.

Progress: In July, Pam attended The Power of the Movement Mid-Year CADCA training held in Orlando, Fl. A number of individual workshops were available for the RPP to attend. UAMS South has as so attended a number of webinars about Health Consequences of Using Marijuana,Effective Outreach and Engagement Strategies for Service Members, Veterans, and their Families, and many other webinars and community training on prevention.

Plan: UAMS South Prevention will attend additional trainings annually and become diverse in behavioral health prevention programming for primary, secondary, and tertiary prevention for selected, indicated, and universal populations. The RPPs are working with Jessica Hestand to receive the information and knowledge to prepare for the prevention certification. Each of the staff will receive the required 100 contact hours of prevention education during the year.

F. Program Deliverables:

The contractor will conduct various behavioral health prevention trainings according to training schedule and provide technical assistance to other DBHS providers and other state, local, and community organizations within the region.

Progress: Pam has worked several safety baby showers in Miller, Little River and Sevier counties providing formation about fetal alcohol syndrome disorders and e-cigs. Literature was given to all that attended. In December 8, Kim held Refusal Skills training for youth at Columbia County Boys & Girls Club. Tia presented the workforce partners with TA about underage drinking.

Plan: UAMS South are planning trainings and technical assistance throughout the region according to the training scheduled. We will focus on providing information on problems area by using data for the APNA. We are will to work with any organization that asks for technical assistance from us in any way that we can.

G. Program Deliverables:

The contractor will work through groups and organizations (especially youth groups) to develop or enhance the local behavioral health prevention and build the local infrastructure. Progress:Pam attends the Little River, Miller, Howard, and Sevier coalition meeting regularly to help assist with prevention related planning in the community. Tia attends the LIFE, PNCHA, AHOC, and HOPE coalitions regularlyto help assist with prevention related planning in the community.Kim regularly attends coalition meetings’ for: HEALTH, TOUCH, DASH and UCRC. Every community coalition meeting is attended by staff or volunteers from our agency. Pam and Tia also attend the Prevention Task Force meetings monthly help the group form ideas for the communities on making positive and health life choices. Pam worked with the youth at the Nashville schools on the Arkansas Drive Smart Challenge program. Tia worked with the Nevada and Prescott school about the Arkansas Drive Smart Challenge. Kim also attended the CHAMPS (Champs Have and Model Positive Skills) Training presented by PRIDE Youth Programs in Union County. This is an evidence based program provided for most upper elementary students in Union County. Kim was able to stay with the youth groups while they progressed through the workshops. Kim attended a coalition meeting of UCRC in November to assist with the planning of Fetal Alcohol Presentations in Calhoun County. Plan:UAMS South Prevention will work through groups and organizations to develop or enhance local behavioral health prevention and build lock infrastructure. There are active youth groups in our four county areas, and we are participating in several youth events so that we can become more familiar with the youth groups. H. Program Deliverables:

The contractor will implement DBHS identified environmental strategies. Environmental strategies must include Synar and Coverage Study.

Progress:Tia and Pam attended a Task Force partners meeting to determine what strategies might need to be implemented in our area to address health problems and issues. We will meet again in January to finalize plans. The Arkansas Drive smart Challenge; Safety Baby Showers; and Stomp Out unhealthy choices were some of the topics discussed. Stomp out health choices was mainly address for our region.

Plan:UAMS South will implement DBHS identified environmental strategies. Environmental strategies will include Synar and Coverage Study. Working with the new groups of youth and schools in our communities will also give us more resources for the Synar Tobacco Compliance Checks.

I. Program Deliverables:

The contractor will assist with the collection of statewide behavioral health prevention data and provide additional technical assistance in data analysis within the region.

Progress: Recruitment for the 2014 APNA begun in August through emails and personal contact with school district officials. As soon as we received the APNA packets from PRIDE Surveys, we emailed, faxed, mailed, and/or delivered the packet to every school district in our region. Each RPP began initial contact with all districts by phone, email, and/or visits. We continued this until we received registrations from all 29 of our 31 schools.

Plan:When the results come in, we will contact the non-participating schools and provide them with the county data. We will make sure that they are contacted by phone or visit. When the regional meetings are set up and we will invite them to attend. We will follow-up with the school to see if we can assist them. We will provide publicity about the regional meetings in newsletters, newspapers, emails, and mail-outs to each community.

J. Program Deliverables:

The contractor will work in collaboration with Treatment Centers, Treatment Providers, Mental Health Centers, Mental Health Providers, HIV Providers, Domestic Violence Providers, Arkansas Department of Health, DBHS Providers, Systems of Care, Children and Adolescent Service System Program, Access To Recovery (ATR) Providers, Drug and Alcohol Safety and Education Program (DASEP) providers, Other Providers.

Progress:Kim has met with South Arkansas Fights AIDS. She has also provided the organization with drug and alcohol prevention literature. Tia worked with DHS/DCFS in Nevada County providing information about underage drinking and prescription drugs. Tia also partner with Arkansas rehab about youth improve in Ouachita County.

Plan:UAMS South Plan to work in collaboration with Treatment Centers, Treatment Providers, Mental Health Centers, Mental Health Providers, HIV Providers, Domestic Violence Providers, Arkansas Department of Health, DBHS Providers, Systems of Care, Children and Adolescent Service System Program, Access To Recovery (ATR) Providers, Drug and Alcohol Safety and Education Program (DASEP) providers, Other Providers. We have work with most providers in the past, but will continue to build stronger partnerships.

K. Program Deliverables:

The contractor will submit required reporting documents to DBHS in a timely manner and enter all appropriate information into the Minimum Data Set (MDS) system.

Progress: Each RPP has entered MDS data into reporting system every month. Invoices for reimbursement have been submitted. Monthly and quarterly reports have been completed each month this far. APNA reports have been completed and logged with new contact information. Plan:UAMS South Prevention will submit required reporting documents to DBHS in a timely manner and enter all appropriate information in the Minimum Data Set (MDS) system.

L. Program Deliverables:

The contractor will maintain program files/records at the RPP program site location. Progress: Each office is maintaining its own program files/records with the Magnolia office holding most of the contract documentation. Each RPP are maintaining any records about their individual functions including how activities were planned and carried out; meeting documents; coalition information; and any information pertinent to their four-county area. Any region-wide event will be located at the Magnolia office.

Plan:UAMS South Prevention will maintain program files/records at the RPP program site location. Special monthly emphasis reports are held at each location.

III. BUSINESS PROPOSAL:

The business proposal consists of the Budget Request and Form SF-424. These should be completed and attached in the following order:

Budget Request:

• Budget Narrative • Budget Summary • Detailed line item—supporting schedule

Forms:

• SF–424 Form – Application for Federal Assistance • Copies of letters to clearinghouses • Grant Disclosure Form • Include 2 copies of completed audit

The Rules of Practice and Procedure, page 40, Section 3.10.2.12, states: Indirect costs shall be allowable only when special approval is given, in writing, from the DBHS. Generally this shall not exceed 10% of the direct cost. Indirect costs are costs incurred by an organization that are not readily identifiable with a particular project or program but are necessary to the operation of the organization and the performance of its program. A cost allocation showing the items and expense included and the method used to equitably distribute the cost should be submitted to DBHS before indirect costs are allowed.

All financial issues are governed by the DBHS Rules of Practice and Procedure. Please refer to this document for guidance.

ARKANSAS DEPARTMENT OF HUMAN SERVICES DIVISION OF BEHAVIORAL HEALTH

PREVENTION SERVICES BUDGET NARRATIVE for 2015-2016

Compensation: Salaries, Fringe, Professional Fees and Services Salaries: The RPP will employ three full-time RPR’s that manage all the required counties in the region. They will be responsible for carrying out all the requirements for their area. The salary for each of these three representatives will be $25,642.67. One full-time clerical assistant will be at a salary of $19,433.00. Salaries will total $96,364.00 Fringe: Staff benefits will be charged at 24% of their salaries. The three full-time RPR’s will have benefits of $6,097.17 each. The full-time clerical assistant will be at $4,620.49. Fringes will total $22,912.00 Reimbursable: Maintenance & General Operations, Conference Fees & Travel, Capital Outlay (Equipment) and Indirect Costs Maintenance& General Operations: All expenses (supplies, office requirements, regional and state travel) are necessary for staff to run this specific project. No other project will utilize any materials from this proposal. All M&O expenses equal $ 27,838.50. Regional and State Travel: The items included in the Regional and State Travel are Per Diem for staff to equal $500; travel within the state for three staff to equal $10,000; Conference Travel and Overnight Hotel for staff equal $7,000. Supplies: The requested supply budget of $5,518.50 will be used for ink cartridges, storage carts, pens and pencils, desk supplies, promo’s, and misc. supplies. Program Requirements: Office requirement will be for the office phone and fax number, copying in all locations, postage in all locations, Synar expenses, equipment, utilities, training, food and supplies, and memberships totaling $13,320. Indirect Costs: 10% of the total direct costs for the proposal is $15,491.50. Total Amount: $170,406.00

ARKANSAS DEPARTMENT OF HUMAN SERVICES DIVISION OF BEHAVIORAL HEALTH

PREVENTION SERVICES BUDGET SUMMARY

PROVIDER University of Arkansas for Medical Sciences

Contract Period: From: 7/1/2015 to 6/30/2016

ADDRESSS 4301 West Markham, Slot 812 Little Rock, AR 72205

BUDGET CATEGORIES DBHS FUNDS CASH OR IN-KIND FUNDS

CATEGORY TOTALS

COMPENSATION:

Regular Salaries

96,364

96,364

Fringe

22,912

22,912

Professional Fees and Services

A. Compensation Subtotal

119,276

119,276

REIMBURSEABLE:

Maintenance & General Operations

27,838.50

27,838.50

Conference Fees & Travel - Expenses to Conferences

7,800.00

7,800.00

B. Reimbursable Subtotal

35,638.50

35,638.50

Indirect Costs

15,491.50 15,491.50

Total Projected Budget

170,406

170,406

Percentage of Total

100% 0% 100%

**Must be accompanied by the detailed line-item supporting schedule**

Salaries

Regional Prevention Representative $ 25,643.67



Administrative

$ 19,433.00

Subtotal $ 96,364.00

Fringe




Administrative

$ 4,620.49


Professional Fees

Accounting/Audit

$ 0.00

Speakers

$ 0.00

Subtotal $ 0.00

Maintenance/ General Operations

Prevention Media Campaign $50 x 12mo $ 600.00

Synar Expenses $100 x 3 staff $ 300.00

Equipment (less than $2500)

$ 1,000.00

Food and Supplies Snacks/refresments for meetings/events x3 staff $ 2,000.00

Office Phone and Fax $150 x 12 mo= $ 1,800.00

Utilities $50 x 12mo= $ 600.00

Memberships $30 x 3 staff $ 90.00

Postage $20 x 12mo $ 240.00

Certification Costs 3 x $150 $ 450.00

Printing $20 x 12mo $ 240.00

Travel non-conference Travel require for in-state/local travel for region $ 10,000.00

Training In state/local training for region $ 5,000.00

Materials and Supplies (please breakdown by item) $ 5,518.50


Conference Travel

Conference Costs Conference Fees for region (3 staff) $ 3,300.00

Conference Lodging Hotel Fees for region (3 staff) $ 3,000.00

Conference Travel Travel for region $ 1,000.00

Conference per diem

$ 500.00

Subtotal $ 7,800.00

Total Expenses $ 35,638.50

Indirect costs $ 15,491.50

(Cannot exceed 10% of Direct Costs)

Total $ 170,406.00

Materials & Supplies Breakdown Expense Calculation

Total Supplies Ink Cartridges 30 x $35= $ 1,050.00 Rolling Storage Cart $30 x 3 staff $ 90.00 Date Books 4 x $26.38= $ 105.50 Pens Promo 1800 x $.50=$900+$150sh= $ 1,050.00 Pencils Promo 1800 x $.40=$720+50sh= $ 1,623.00 Multi-purpose paper 24 x $35= $ 840.00 Business cards 4 boxes x $40= $ 160.00 Desk Supplies $50 x 4 staff $ 200.00 UAMS South Shirts 4 x $25= $ 100.00 Candy & Door Prize Health fairs $100 x 3 staff $ 300.00

$ 5,518.50

ARKANSAS DEPARTMENT OF HUMAN SERVICES

PERFORMANCE BASED CONTRACTING NOTE: These Performance Based Standards are EXAMPLES ONLY and represent the types of indicators which will be included in the contract. Pursuant to Ark. Code Ann. 19-11-1010 et. seq., the selected contractor shall comply with performance based standards. Following are the performance based standards that will be a part of the contract and with which the contractor must comply for acceptable performance to occur under the contract. I. The contract must comply with all statutes, regulations, codes, ordinances, licensure or certification requirements applicable to the contractor or to the contractor’s agents and employees and to the subject matter of the contract. Failure to comply shall be deemed unacceptable performance. II. The contractor agrees to hold the contracting Division/Office harmless and to indemnify the contracting Division/Office for any additional costs of alternatively accomplishing the goals of the contract, as well as any liability, including liability for costs or fees, which the contracting Division/Office may sustain as a result of the contractor’s performance or lack of performance. III. During the term of the contract, the Division/Office will complete sufficient performance evaluation(s) to determine if the contractor’s performance is acceptable. IV. The contract program deliverables and performance indicators to be performed by the contractor are: A. Performance Deliverable: The contractor will raise community awareness of behavioral health prevention through media campaigns and public presentations and dissemination of prevention materials such as pamphlets and brochures, etc.by promoting and attending awareness events. Performance Indicator: 1. The contractor will promote and attend awareness projects specifically for Military Yellow Ribbon (August), Fetal Alcohol Spectrum Disorder (September), Suicide Prevention (September). Recovery Month (September), Red Ribbon Week (October), National Substance Abuse Prevention Month (October), Bullying Prevention Month (October), Domestic Violence Month (October), Great American Smoke-out (November), Drugged and Drunk Driving (December), Gambling (March), Kick Butts Day (March), Child Abuse Awareness Month (April), National Prevention Week (April), Alcohol Awareness (April), National Prevention Week (May), Mental Health Awareness (May), and World No Tobacco Day (May). Acceptable Performance 1. The contractor will maintain a file for each awareness/campaign promoted and/or attended. File to include promotional materials utilized, sign-in-sheets, news articles, completed evaluation summaries, event pictures, PowerPoint presentations, handouts, DBHS approvals, etc. 2. The contractor will submit for DBHS approval of proposed media/printed materials (PSAs, Flyers, etc.) to be utilized for awareness. (All printed materials (media) will be subject to DBHS approval. Contract must also abide by the guidelines in the Behavioral Health Prevention Model when developing materials for dissemination.) 3. The contractor will promote and/or attend at least one awareness project every month.

4. The contractor will provide narrative and description of the activity in submitted quarterly reports to DBHS and entered awareness activities into Minimum Data Set (MDS) monthly. Method/Frequency of Monitoring DBHS prevention staff will contact program staff monthly by email, conference calls, and/or individual calls regarding the progress of community awareness and provide technical assistance. DBHS prevention staff will also review MDS data, review quarterly reports, and perform annual site visits to review files and documentation. B. Performance Deliverable: The contractor will utilize the Strategic Prevention Framework (SFP) in planning behavioral health prevention projects: Special projects specifically for Military Yellow Ribbon (August), Fetal Alcohol Spectrum Disorder (September), Suicide Prevention (September), Recovery Month (September), Red Ribbon Week (October), Domestic Violence Month (October), Great American Smoke-out (November), Drugged and Drunk Driving (December), Gambling (March), Kick Butts Day (March), Child Abuse Awareness Month (April), National Prevention Week (April), Alcohol Awareness (April), National Prevention Week (May), Mental Health (May), and No Tobacco Day (May) Performance Indicator 1. The contractor will plan at least five (5) special projects specifically for behavioral health prevention within the region Acceptable Performance 1. The contractor will maintain a file for each awareness/campaign project planned. File to include promotional materials utilized, sign-in-sheets, news articles, completed evaluation summaries, event pictures, PowerPoint presentations, handouts, DBHS approvals, etc. 2. The contractor will document the SPF process for each special project planned. 3. The contractor will submit for DBHS approval of proposed media/printed materials (PSAs, Flyers, etc.) to be utilized for awareness. (All printed materials (media) will be subject to DBHS approval. Contractor must also abide by the guidelines in the DBHS Prevention Principles, Guidelines and Models for Behavioral Health System when developing materials for dissemination.) 4. The contractor will provide narrative and description of the activity in submitted quarterly reports to DBHS and entered all special projects (awareness/campaigns) attended or participated in into MDS monthly. Method/Frequency of Monitoring DBHS prevention staff will contact program staff monthly by email, conference calls, and/or individual calls regarding the progress of community awareness and provide technical assistance. DBHS prevention staff will also review MDS data, review quarterly reports, and perform annual site visits to review files and documentation. C. Performance Deliverable: The contractor will operate as “Prevention Outlet” for dissemination of information and behavioral health prevention materials (pamphlets and brochures, videos, etc.) Performance Indicator: 1. The contractor will maintain an identified area as the “Prevention Outlet.” 2. The contractor will disseminate prevention materials and information regarding behavioral health prevention.

3. The contractor will track all disseminated materials and materials utilized through inventory logs and distribution logs documentation. Acceptable Performance 1. The contractor will maintain a log of prevention materials disseminated 2. The contractor will maintain an ongoing inventory of prevention materials 3. The contractor will obtain appropriate and sufficient prevention materials and information for dissemination. (Contractor must abide by the guidelines in the Behavioral Health Prevention Model when developing materials for dissemination.) 4. The contractor will enter all materials disseminated through the “Prevention Outlet” into MDS monthly. Method/Frequency of Monitoring DBHS prevention staff will review MDS data monthly, review quarterly reports, and perform annual site visits to review documentation and observe the “Prevention Outlet” layout. D. Performance Deliverable: The contractor will become knowledgeable in various prevention methodologies by attending the Division of Behavioral Health Services (DBHS) identified Training of Trainers (TOT) and other identified TOT. The contractor will be required to conduct each of the trainings in the region. Performance Indicator 1. The contractor will become certified as a Training of Trainers (TOT) in identified DBHS training curricula 2. The contractor will deliver each of the TOT trainings in the region (i.e. -newest version of Substance Abuse Prevention Skills Training (SAPST), Prevention Fundamentals, Love and Logic, Lead and Seed/Lead and Seed Refresher) 3. The contractor will have the option to seek additional Training of Trainers (TOT) for implementation in the region. (Participation in other identified Training of Trainers (TOT) must receive prior approval by DBHS.) Acceptable Performance 1. The contractor will attend all mandated trainings by DBHS and obtained a current certificate of completion from the TOT provider 2. The contractor will submit appropriate documentation (certificate) of completion of all TOT trainings to DBHS 3. The contractor will submit a training schedule for proposed TOT trainings in the region to DBHS. (Training schedule to include logistics and population serving.) 4. The contractor will enter all Training of Trainers (TOT) trainings attended into MDS Method/Frequency of Monitoring DBHS prevention staff will review MDS data monthly, review quarterly reports, and perform annual site visits to review completed training documentation. E. Performance Deliverable: The contractor will attend additional trainings annually and become diverse in behavioral health prevention (treatment, mental health, and recovery) programming for primary, secondary, and tertiary prevention for selected, indicated, and universal populations. Performance Indicator

1. The contractor will attend hosted DBHS identified evidence-based program trainings - Guiding Good Choices, Strengthening Families, Team Awareness and Team Readiness, and other evidence based trainings identified by DBHS) 2. The contractor will research, select, and attend 2 (two) additional evidence-based program trainings (Trainings must be approved by DBHS. The contractor’s selection should be based on the regional/community needs. Additional evidence-based training proposed costs must be reflective in the budget.) 3. The contractor will attend DBHS identified behavioral health prevention, treatment, mental health, and recovery trainings (i.e. Mental Health First Aide, trainings by The Change Companies; WRAP Around 101; ASIST trainings, Gatekeepers trainings, and military cultural trainings) 4. The contractor will ensure staff will obtain 100 contact hours and continuing education units (CEUs) in behavioral health prevention and/or related prevention programming and planning Acceptable Performance 1. The contractor will attend all mandated evidence-based trainings identified by DBHS and obtained documentation (certificates) of completion. 2. The contractor will select and attended two evidence-based trainings and obtained documentation (certificates) of completion (Evidence-based training must be approved by DBHS Staff.) 3. The contractor will submit appropriate documentation (certificates) of completion of evidence-based trainings and other identified trainings 4. The contractor will submit to DBHS a training schedule to obtain 100 combined hours in contact hours and continuing education units (CEUs) in behavioral health prevention (inclusive of prevention, treatment, mental, and recovery) programming 5. The contractor will enter all trainings attended into MDS monthly Method/Frequency of Monitoring DBHS prevention staff will review MDS data monthly, review quarterly reports, and perform annual site visits to review training documentation. F. Performance Deliverable: The contractor will conduct various behavioral health prevention trainings according to training schedule and provide technical assistance to other DBHS providers and other state, local, and community organizations within the region Performance Indicator 1. The contractor will conduct parenting classes at public venues using one of the following curriculums: Love and Logic, Guiding Good Choices, Mental Health First Aide, or Strengthening Families. (Referrals for the class may be obtained from treatment centers, courts, Division of Children and Family Services (DCFS), Division of Youth Services (DYS), faith based organizations, or mental health centers.) 2. The contractor will conduct Team Awareness and Team Readiness with military and their families in collaboration with Mid-South Prevention Institute. 3. The contractor will conduct the newest version of Substance Abuse Prevention Skills Training (SAPST) training in collaboration with Mid-South Prevention Institute 4. The contractor will conduct Prevention Fundamentals Training 5. The contractor will conduct Lead and Seed trainings with youth groups 6. The contractor will co-present Merchant Education Training 7. The contractor will co-present Alcohol Beverage Training 8. The contractor will co-present Tobacco Training 9. The contractor will provide follow-up technical assistance for Lead and Seed, Team Awareness, Team Readiness, and SAPST or Prevention Fundamentals.

10. The contractor will conduct other trainings and technical assistance related to substance abuse or mental health prevention as requested Acceptable Performance 1. The contractor will plan and conduct at minimum 4 (four) replications of parenting classes at public venues using one of the following curriculums: Love and Logic; Guiding Good Choices, Mental Health First Aide, or Strengthening Families. Referrals for the class may be obtained from treatment centers, courts, Division of Children and Family Services (DCFS), Division of Youth Services (DYS), faith based organization, or mental health centers. 2. The contractor will plan and conduct at a minimum 1 (one) Team Awareness and Team Readiness with military and their families in collaboration with Mid-South Prevention Institute. 3. The contractor will plan and conduct at a minimum 1 (one) the newest version of Substance Abuse Prevention Skills Training (SAPST) training in collaboration with Mid-South Prevention Institute. 4. The contractor will plan and conduct at a minimum 1 (one) Prevention Fundamentals training within the region. 5. The contractor will plan and conduct at minimum 3 (three) different Lead and Seed trainings with youth groups. 6. The contractor will co-present at minimum of 1 (one) Merchant Education Training 7. The contractor will co-present at minimum of 1 (one) Alcohol Beverage Training 8. The contractor will co-present at minimum of 1 (one) Tobacco Training 9. The contractor will provide follow-up technical assistance for Lead and Seed, Team Awareness, Team Readiness, SAPST or Prevention Fundamentals. 10. The contractor will plan and conduct other trainings and provided technical assistance related to substance abuse or mental health prevention as requested with no more than 3 (three) presentations each quarter. 11. The contractor will maintain a file for all trainings and technical assistance completed. File to include but not limited to training materials utilized, sign-in-sheets, news articles, completed evaluation/evaluation summaries, completed pre/posttests, event pictures, PowerPoint presentations, handouts, DBHS approvals, requests for services, etc., and documented Strategic Prevention Framework (SPF) process. 12. The contractor will provide narrative and description of the trainings in submitted quarterly reports to DBHS and enter all conducted prevention trainings and technical assistance performed into MDS monthly-reflecting the CSAP Strategy, Population Served, and Number Served. Method/Frequency of Monitor DBHS prevention staff will review MDS data monthly, review quarterly reports, and perform annual site visits to review completion of training and technical assistance documentation. G.Performance Deliverable: The contractor will work through groups and organizations (especially youth groups) to develop or enhance the local behavioral health prevention and build the local infrastructure Performance Indicator 1. The contractor will establish Lead & Seed Youth Coalitions within the region 2. The contractor will maintain Lead & Seed Youth Coalitions within the region 3. The contractor will provide Strategic Prevention Framework (SPF) training and technical assistance to youth groups and other identified groups within the region. Acceptable Performance 1. The contractor will establish at a minimum 3 Lead and Seed youth groups within the region 2. The contractor will provide “Lead and Seed” training to a minimum of 5 potential Lead and Seed youth coalitions within the region. 3. The contractor will communicate/meet with established Lead and Seed Youth adult leaders monthly. 4. The contractor will provide Strategic Prevention Framework (SPF) training and technical assistance to a minimum of 3 (three) other identified groups within the region.

5. The contractor will provide technical assistance in strategic prevention framework to current and newly established Lead and Seed Youth Coalitions and other identified groups 6. The contractor will maintain a file to document flyers, presentation notes, information brochures showing recruitment within the region for the establishment of youth coalitions; sign-in-sheets for initial meetings, copies of minutes, and documented trainings of youth groups and other identified groups; documentation of other technical assistance provided; 7. The contractor will provide narrative and description of the development and enhancement of the local behavioral health prevention and infrastructure in submitted quarterly reports to DBHS 8. The contractor will enter all activities, trainings, and technical assistance performed into MDS monthly-reflecting the CSAP Strategy, Population Served, and Number Served. Method/Frequency of Monitoring DBHS prevention staff will review MDS data monthly, review quarterly reports, and perform annual site visits to review the establishment and maintenance of Lead and Seed Youth Coalitions. H.Performance Deliverable: The contractor will implement DBHS identified environmental strategies. Environmental strategies must include Synar and Coverage Study. Performance Indicator 1. The contractor will conduct the annual Synar compliance checks for tobacco accessibility within the region 2. The contractor will conduct the periodic Coverage Study to assure validity of the merchant list, when mandated by the federal government. 3. The contractor will attend the mandated training(s) prior to conducting Synar compliance checks and/or Coverage Study. 4. The contractor will adhere to the Synar and Coverage Study DBHS protocols Acceptable Performance 1. The contractor will ensure 100% Compliance Checks will be completed and documented accurately. 2. The contractor will ensure youth documentation and parent consent forms for all youth participants will be completed accurately and submitted to DBHS. 3. The contractor will submit complete and accurate forms, pictures, youth demographics, and any purchased tobacco to Arkansas Department of Health and successful buy forms to Arkansas Tobacco Control Board by the established deadline. 4. The contractor will conduct coverage study by the established deadline as instructed during federally designated years 5. The contractor will ensure 100% Coverage study will be completed and documented accurately. 6. All Forms detailing costs associated with conducting Synar compliance checks and/or coverage study will be completed accurately. 7. The contractor will maintain separate files for Synar and Coverage Study documents. 8. The contractor will ensure that all required Synar and Coverage Study documentation will be submitted by the deadline to the designated/appropriate DBHS provider 9. The contractor will ensure that all Synar and/or Coverage Study activities will be entered into MDS. Method/Frequency of Monitoring Parent consent, youth recruitment, and compliance check schedule will be submitted to DBHS two weeks before the annual training and DBHS will provide approval within one week of submission. Sign-in-sheets for compliance training and coverage study training will be monitored by DBHS. Compliance check forms, pictures and purchased

tobacco will be submitted to Arkansas Department of Health and successful buy forms to Arkansas Tobacco Control by the date set by these entities. DBHS will monitor for these submissions by contacting the two entities periodically during the compliance check time period. Coverage study forms will be submitted to Arkansas Department of Health and DBHS will monitor by contacting this entity during the assigned time period. Forms detailing costs will be submitted at the completion of the compliance check and coverage study to DBHS and DBHS will provide feedback within one month. I. Performance Deliverable: The contractor will assist with the collection of statewide behavioral health prevention data and provide additional technical assistance in data analysis within the region. Performance Indicator 1. The contractor will recruit for the annual Arkansas Prevention Needs Assessment (APNA) webinar 2. The contractor will contact all schools within the region and ask for participation in the APNA survey 3. The contractor will submit school agreement forms to survey contractor 4. The contractor will act as a liaison with the APNA provider to follow-up on contacts with schools (i.e. email, calls, letters, visit, need assistance with administrating surveys, received surveys, submit completed surveys back to survey contractor) 5. The contractor will provide any additional technical assistance of data analysis to the region/community upon requests. Acceptable Performance 1. The contractor will contact 100% percent of schools within the region for APNA participation 2. The contractor will secure 80% successful recruitment rate. 3. The contractor will fax all completed agreement forms to APNA provider (International Survey Associates-ISA) and DBHS by the established deadline. 4. The contractor will contact 100% all participating schools in the region and offered assistance for the completion of the survey. 5. The contractor will email schools officials and other key stakeholders about the APNA webinars 6. The contractor will promote the APNA webinars through media for public attendance. Method/Frequency of Monitoring The Division of Behavioral Health Services (DBHS) will review tracking information about school participation as supplied by survey contractor and provide feedback to contractors about percentage of schools participating or schools that are late returning the surveys. The contractor will maintain records of emails about promotion of the webinar and DBHS will review documents during an annual site visit. This deliverable occurs once a year only during the first part of the contract year and will be monitored only during that time. J. Performance Deliverable: The contractor will work in collaboration with Treatment Centers, Treatment Providers, Mental Health Centers, Mental Health Providers, HIV Providers, Domestic Violence Providers, Arkansas Department of Health, DBHS Providers, Systems of Care, Children and Adolescent Service System Program, Access To Recovery (ATR) Providers, Drug and Alcohol Safety and Education Program (DASEP) providers, Other Providers. Performance Indicator 1. The contractor will make contact with the listed partners to discuss collaborative services. 2. The contractor will develop linkages with community health and wellness partners. 3. The contractor will serve on Advisory Councils, Boards, Task Forces etc. as requested by DBHS. 4. The contractor will maintain monthly contact with key officials and stakeholders in the community.

Acceptable Performance The contractor will maintain record of meetings with community partners through agendas and/or notes. The contractor will develop Memorandum of Agreements (MOA) or Memorandum of Understandings (MOU) with partners to outline agreed upon services. Method/Frequently of Monitoring DBHS will monitor collaboration records during the annual site visit and feedback will be provided with the results of the visit. K. Performance Deliverable: The contractor will submit required reporting documents to DBHS in a timely manner and enter all appropriate information into the Minimum Data Set (MDS) system. Performance Indicator 1. The contractor will submit a monthly invoice for reimbursement. 2. The contractor will submit quarterly narrative reports documenting progress. 3. The contractor will enter all monthly prevention activities into the MDS system. Acceptable Performance 1. The contractor will submit all monthly invoices by the 15th of each month (previous month paid expenditures). 2. The contractor will submit quarterly reports by the 15th of the month following the end of the quarter. (1st Quarter: October to December; 2nd Quarter: January to March; 3rd Quarter: April to June; and 4th Quarter: July to September) 3. The contractor will enter monthly data in the MDS system by the 15th of each month (previous month’s prevention activities). 4. The contractor will meet and comply with the performance deliverables. Method/Frequency of Monitoring DBHS will review and track all reporting documents and provide feedback/technical assistance when needed. DBHS program staff will access reports from MDS on a monthly, quarterly, and annual basis. L. Performance Deliverable: The contractor will maintain program files/records at the RPP program site location. Performance Indicator 1. The contractor will keep records/files by the project period for program documents, personnel documents, and financial documents at the site location in a manner to be easily accessible. Acceptable Performance 1. The contractor will maintain Program Files to include but not limited to program documents related to the tasks performed and scope of work achieved. 2. The contractor will maintain Personnel Files to include but not limited to current job descriptions, resumes, completed time sheets, etc. 3. The contractor will maintain Program Financial Records to include but limited to copies of monthly expenditures that coincide with the monthly, submitted invoices, general ledgers, etc. Method/Frequency of Monitoring

DBHS will review program files and records during an annual site visit and provide feedback about the results of the visit within two weeks after the visit. REMEDIES FOR UNACCEPTABLE PERFORMANCE Acceptable performance shall be determined solely at the discretion of the contracting division. One or more of the following remedies may be imposed for unacceptable performance. 1. The contracting division will notify the contractor of unacceptable performance. A meeting between the division and contractor will take place to discuss and develop an informal plan for change. 2. The contracting division will notify the contractor in writing of non-compliance with the program deliverable and performance indicators for that program deliverable. Within ten working days of notification of non-compliance, contractor must submit and implement a corrective action plan that is acceptable to the contracting division or its designee. Pending submission and implementation of an acceptable corrective action plan, payment may be reduced or withheld as determined by the contracting division. 3. The contract may be terminated. The remedies listed above are in addition to all others available by law or equity.

SUBMISSION INFORMATION

Critical Dates

December 19, 2014 Notice of continuation funding announced January 12, 2015 Completed applications must be returned to DBHS by

12:00 p.m. noon ( no applications will be accepted after this deadline)

A. Application Deadline

The deadline for submitting continuation applications is January 12, 2015. Continuation applications must be physically complete and present in the DBHS office no later than 12:00 p.m. (noon) on January 12, 2015. Applications that do not meet this deadline requirement will be returned unopened.

B. Delivery

1. Mail or deliver the original (1) and two (2) copies (a total of 3 documents). All applications must be received by the deadline date and time. The original application must be designated and blue ink signatures are necessary on all required forms in the application marked original. Late applications, those that submit less than the required original and 3copies or applications that are not complete and/or properly collated by page number will not be reviewed. A date and time stamp will be used to determine receipt of applications.

FAXED APPLICATIONS WILL NOT BE ACCEPTED.

Applications submitted by mail should be delivered to the following address: DEPARTMENT OF HUMAN SERVICES

DIVISION OF BEHAVIORAL HEALTH ATTN: PREVENTION SERVICES 4800 W. 7TH STREET LITTLE ROCK AR 72205 AND

2. Email an electronic copy (Microsoft word document) to: Marshelvia Thompson-Collins-Grants Analyst/Project Officer, Prevention Services Email: [email protected]

Submission and Award Information

CC: Kymala Calloway - [email protected]

STATE AND AREAWIDE CLEARINGHOUSES

ARKANSAS STATE CLEARINGHOUSE (SPOC) P.O. BOX 8031 MANAGER: TRACY L. COPELAND 1515 WEST 7TH Room 305 SECRETARY: CHERRY CUNNINGHAM LITTLE ROCK, AR 72203-8031 PHONE: (501) 682-1074 FAX: (501) 682-5206 [email protected] [email protected] #1 CENTRAL ARKANSAS PLANNING AND DEVELOPMENT DISTRICT, INC. 902 N. CENTER EXEC. DIRECTOR: RODNEY LARSEN P.O. BOX 300 CONTACT: CONYA SPENCER LONOKE, AR 72086-0300 PHONE: (501) 374-4669, or (501) 676-2721 FAX: (501) 676-5020 EMAIL: www.capdd.org COUNTIES SERVED: LONOKE, PRAIRIE, MONROE, FAULKNER (PULASKI & SALINE) #2 WHITE RIVER PLANNING AND DEVELOPMENT DISTRICT, INC. 1652 WHITE DR. EXEC. DIRECTOR: VAN C. THOMAS P. O. BOX 2396 CONTACT: GAYE YATES BATESVILLE, AR 72503 PHONE: (870) 793-5233 FAX: (870) 793-4035 EMAIL: www.wrpdd.org COUNTIES SERVED: WHITE, CLEBURNE, WOODRUFF, JACKSON, SHARP, FULTON, IZARD, STONE, VAN BUREN, AND INDEPENDENCE #3 EAST ARKANSAS PLANNING AND DEVELOPMENT DISTRICT, INC. 2905 KING STREET EXEC. DIRECTOR: MELISSA RIVERS P. O. BOX 1403 CONTACT: EMILY HATHCOCK JONESBORO, AR 72403 PHONE: (870) 932-3957 FAX: (870) 932-0135 EMAIL: www.eapdd.com COUNTIES SERVICED: RANDOLPH, CLAY, GREENE, LAWRENCE, CRAIGHEAD CROSS, POINSETT, MISSISSIPPI, ST. FRANCIS, LEE, PHILLIPS, (CRITTENDEN)

Appendices

#4 NORTHWEST ARKANSAS ECONOMIC DEVELOPMENT DISTRICT, INC. 818 HWY 62-65 412 NORTH EXEC. DIRECTOR: MIKE NORTON P. O. BOX 190 CONTACT: LIBBY ROBINSON HARRISON, AR 72602-0190 PHONE: (870) 741-5404 FAX: (870) 741-1905 EMAIL: www.nwaedd.org COUNTIES SERVED: MADISON, CARROLL, BOONE, MARION, BAXTER, SEARCY, NEWTON, (BENTON & WASHINGTON) #5 SOUTHEAST ARKANSAS ECONOMIC DEVELOPMENT DISTRICT, INC. 721 S. WALNUT EXEC. DIRECTOR: GLENN E. BELL

P. O. BOX 6806 CONTACT: MONICA TUCKER PINE BLUFF, AR 71611 PHONE: (870) 536-1971 FAX: (870) 536-7718 EMAIL: COUNTIES SERVED: ASHLEY, BRADLEY, CHICOT, CLEVELAND, DESHA,

DREW, GRANT, ARKANSAS, LINCOLN (JEFFERSON) #6 SOUTHWEST ARKANSAS PLANNING AND DEVELOPMENT DISTRICT 101 BUSINESS PARK DRIVE EXEC. DIRECTOR: RENEE DYCUS P.O. BOX 767 CONTACT: SHELLEY MOREHEAD MAGNOLIA, AR 71753-2322 PHONE: (870) 234-4030 FAX: (870) 234-0135 EMAIL: www.swapdd.com COUNTIES SERVED: DALLAS, CALHOUN, COLUMBIA, HEMPSTEAD, HOWARD, UNION,

LITTLE RIVER, LAFAYETTE, NEVADA, OUACHITA, SEVIER, (MILLER) #7 WEST CENTRAL ARKANSAS PLANNING AND DEVELOPMENT DISTRICT 1000 CENTRAL AVE EXEC. DIRECTOR: DWAYNE PRATT P.O. BOX 6409 CONTACT: MARY JANE HAZEN

HOT SPRINGS, AR 71902 PHONE: (501) 525-7577 FAX: (501) 525-7677 EMAIL: www.wcapdd.dina.org COUNTIES SERVED: CLARK, CONWAY, GARLAND, HOT SPRING, JOHNSON, POPE, PERRY, PIKE, MONTGOMERY, YELL #8 WESTERN ARKANSAS PLANNING AND DEVELOPMENT DISTRICT 1109 SOUTH 16th STREET EXEC. DIRECTOR: JOHN GUTHRIE P.O. BOX 2067 CONTACT: RHONDA BELL FORT SMITH, AR 72902 PHONE: (479) 785-2651 FAX: (479) 785-1964 EMAIL: www.wapdd.org COUNTIES SERVED: LOGAN, FRANKLIN, POLK, SCOTT, SEBASTIAN AND CRAWFORD #9 FRONTIER METROPOLITAN PLANNING ORGANIZATION

1109 SOUTH 16TH STREET EXEC. DIRECTOR: JOHN GUTHRIE P. O. BOX 2067 CONTACT: RHONDA BELL FORT SMITH, AR 72902 PHONE: (479) 785-2651 FAX: (479) 785-1964 EMAIL: www.frontiermpo.org COUNTIES SERVED: CRAWFORD AND SEBASTIAN #10 METROPLAN 501 WEST MARKHAM STREET EXEC. DIRECTOR: JIM MCKENZIE SUITE B CONTACT: RICHARD K. MAGEE LITTLE ROCK, AR 72201 PHONE: (501) 372-3300 FAX: (501) 372-8060 EMAIL: www.metroplan.org COUNTIES SERVED: PULASKI AND SALINE #11 SOUTHEAST ARKANSAS REGIONAL PLANNING COMMISSION 1300 OHIO STREET EXEC. DIRECTOR: LARRY REYNOLDS P.O. BOX 8398 CONTACT: LARRY REYNOLDS PINE BLUFF, AR 71611 PHONE: (870) 534-4247 FAX: (870) 534-1555 EMAIL: www.searpc.com COUNTIES SERVED: JEFFERSON #12 ARK-TEX COUNCIL OF GOVERNMENTS 4808 ELIZABETH STREET EXEC. DIRECTOR: L.D. WILLIAMSON P. O. BOX 5307 CONTACT: SHARON PIPES TEXARKANA, TX. 75505 PHONE: (903) 832-8636 FAX: (903) 832-3441 EMAIL: www.atcog.org COUNTIES SERVED: MILLER #13 NORTHWEST ARKANSAS REGIONAL PLANNING COMMISSION 1311 CLAYTON EXEC. DIRECTOR: JEFF HAWKINS SPRINGDALE, AR 72762 CONTACT: JEFF HAWKINS PHONE: (479) 751-7125 FAX: (479) 751-7150 EMAIL: www.nwarpc.org COUNTIES SERVED: BENTON AND WASHINGTON

OMB APPROVAL N. 0348-0043

APPLICATION FOR FEDERAL ASSISTANCE

2. DATE SUBMITTED 1/12/2015

APPLICANT IDENTIFIER

1. TYPE OF SUBMISSION: Application Pre-Application ___ Construction ___ Construction

3. DATE RECEIVED BY STATE

STATE APPLICATION IDENTIFIER

X Non-Construction ___ Non-Construction

4. DATE RECEIVED BY FEDERAL AGENCY

FEDERAL IDENTIFIER

5. APPLICANT INFORMATION LEGAL NAME: University of Arkansas for Medical Sciences

ORGANIZATION UNIT: Office of Research and Sponsored Programs

ADDRESS (GIVE CITY, COUNTY, STATE, AND ZIP CODE): 4301 w. Markham Slot 812 Little Rock, AR 72205

NAME AND TELEPHONE NUMBER OF THE PERSON TO BE CONTACTED ON MATTERS INVOLVING THIS APPLICATION (GIVE AREA CODE) Suzanne Alstadt 501-686-5502

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

1-71 - 6046242-A1

7. TYPE OF APPLICANT: (ENTER APPROPRIATE LETTER IN BOX) A. STATE H. INDEPENDENT SCHOOL DIST B. COUNTY I. STATE CONTROLLED INST. OF HIGHER LEARNING

8. TYPE OF APPLICATION:

__ NEW XCONTINUATION REVISION IF REVISION, ENTER APPROPRIATE LETTER(S):

C. MUNICIPAL J. PRIVATE UNIVERSITY D. TOWNSHIP K. INDIAN TRIBE E. INTERSTATE L. INDIVIDUAL F. INTERMUNICIPAL M. PROFIT ORIGINATION G. SPECIAL DISTRICT N. OTHER (SPECIFY):

A. INCREASE AWARD B. DECREASE AWARD C. INCREASE DURATION D. DECREASE DURATION E. OTHER (SPECIFY): ______________________

9. NAME OF FEDERAL AGENCY:

US Department of Health and Human Services/ US Department of Education

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

9 3 9 5 9

11. DESCRIPTIVE TILE OF APPLICANTS PROJECT: Region 7 Regional Prevention Provider-to build substance abuse prevention capacity within the region and communities to address NOMS and assist with statewide prevention infrastructure

12. AREAS AFFECTED BY PROJECT (CITIES, COUNTIES, STATES, ETC.): Calhoun, Columbia, Dallas, Hempstead, Howard, Lafayette, Little River, Miller, Nevada, Ouachita, Sevier, Union

13. PROPOSED PROJECT: 14. CONGRESSIONAL DISTRICT OF: START DATE 7/1/2015

ENDING DATE: 6/30/2016

A. APPLICANT: AR-002

B. PROJECT: AR-004

15. ESTIMATED FUNDING: 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?

A. FEDERAL $ 170,406

A YES, THIS APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ONE

B. APPLICANT $

DATE:

C. STATE $

B. NO PROGRAM IS NOT COVERED BY E.O. 12372

D. LOCAL $

OR PROGRAM HAS NOT BEEN SELECTED BY THE STATE FOR REVIEW

E. OTHER $

F. PROGRAM INCOME $

17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

G. TOTAL $ 170,406

YES IF “YES” ATTACH AN EXPLANATION XNO

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED

TYPED NAME OF AUTHORIZED REPRESENTATIVE Suzanne Leslie

TITLE Director of Contract Services

C. TELEPHONE NUMBER 501-686-6134

D. SIGNATURE OF AUTHORIZED REPRESENTATIVE E. DATE SIGNED

STANDARD FORM 424 (REV 4-88) PRESCRIBED BY OMB CIRCUIT A-1

Attachment C-1 This is a standard form used by applicants as required for Federal assistance. It will be used by Federal agencies to obtain applicant certification. States established a review and document procedure in response to Executive Order 12372, have selected the program to be included in their process and have been given an opportunity to review the applicant’s submission.

ITEM ENTRY ITEM ENTRY

1. Self-explanatory. 10. Use the Catalog of Federal agency from which assistance is being requested.

2. Date application submitted to Federal agency (or State if applicable) & applicant’s control number (if applicable).

11. Enter a brief descriptive title of the project. If more than one program is involved, you should append an explanation on a separate sheet. If appropriate (e.g., construction or real property projects), attach a map showing project location. For pre-applications, use a separate sheet to provide a summary description of this project.

3. State use only (if applicable) 12. List only the largest political entities affected (e.g., state, counties, cities).

4. If this application is to continue or revise an existing award, enter present Federal identifier number. If for a new project, leave blank.

13. Self-explanatory.

5. Legal name of applicant, name of primary organizational unit which will undertake the assistance activity, complete address of the applicant, and name and telephone number of the person to contact on matters related to this application.

14. List the applicant’s Congressional District and any districts(s) affected by the program or project.

6. Enter employer Identification Number (EIN) as assigned by the Internal Revenue Service.

15. Amount requested or to be contributed during the first funding/budget period by each contributor. Values of in-kind contributions should be included on appropriate lines as applicable. It the action will resort in a dollar charge to an existing award, indicate only the amount to the change. For decreases, enclose the amounts in parentheses. If both basic and supplemental amounts are included, show breakdown on an attached sheet. For multiple program funding, use total and show breakdown using same categories as item 15.

7. Enter the appropriate letter in the space provided. 16. Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to

determine whether the application is subject to the state intergovernmental review process.

8. Check appropriate letter in the space provided: ___ “New” means a new assistance award. ___ “Continuation” means an extension for an additional funding/budget period for a project with a projected completion date. ___ “Revision” means any change in the Federal Government’s financial obligation or contingent liability for an existing obligation.

17. This question applies to the applicant organization, not the persons who signs as the authorized representative. Categories of debt include delinquent audit disallowances, loans and taxes.

9. Name of Federal agency from which assistance is being requested with this application.

18. To be signed by the authorized representative of the applicant. A copy of the governing body’s authorization for you to sign this application as official representative must be on file in the applicant’s office. (Certain Federal agencies may require that this authorization be submit as part of the application.)